Provider Demographics
NPI:1255723797
Name:OLORUNOJE, IBUNKUN (PA)
Entity type:Individual
Prefix:
First Name:IBUNKUN
Middle Name:
Last Name:OLORUNOJE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 CLARKSON AVE # ED
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2012
Mailing Address - Country:US
Mailing Address - Phone:718-270-8289
Mailing Address - Fax:
Practice Address - Street 1:210 N TUSTIN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3807
Practice Address - Country:US
Practice Address - Phone:888-959-5192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-20
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10313257164W00000X
NY024382363A00000X
CA62386363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No164W00000XNursing Service ProvidersLicensed Practical Nurse